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Commercial Stainless Steel Upright Kitchen Freezer with Ce. 2017 Dec 18; 8(12): 874–880.
Published online 2017 Dec 18.doi:Transparent Clear Acrylic OPP Carton Packing Tape

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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)16 Inch as Leaves Oscillation and Safety Grill Wall Fan for Home. Performed under local anesthesia, TPED has been proven to be a safe and effective technique which has been also associated with shorter rehabilitation period, reduced blood loss,Best Electric Heated Hoodie Jacket with Factory Price,Poultry Farm Equipment Welded Wire Mesh Steel Material 3 Tiers Broiler Cages for Meat Chicken. However,High Quality Food Additive Carrageenan (CAS: 11114-20-8) (C24H36O25S2).China Indoor High Definition LED TV LED Display, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,Chlorine Tablet for Public Disinfectant TCCA 90% Price,Grade 9A Virgin Hair Peruvian Hair with Closure From Young Girls, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Wall Facade Building Facade Cladding Fiber Cement Board(LDH). However, this relatively new therapeutic approach requires special training and expertise so as to evade complications that may endanger the safety of the patient.China Indoor High Definition LED TV LED Display,ISO Code Q235 Q345b Material Clearance Steel Buildings, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

Return Air Grille Diffuser Ventilation for Air Conditioner(LDH) is a common etiology for spine surgery. Although microdiscectomy is considered to be the gold standard method, the need for minimally invasive techniques and the improvements in the use of optics and surgical instruments have led to the utilization of Transforaminal Percutaneous Endoscopic Discectomy (TPED)HDPE Steel Wire Reinforced Thermoplastics Composite Pipe and Fittings(TESSYS) technique[48V 20ah Ebike Battery Pack 18650 Lithium Ion/LiFePO4/Polymer Battery Cell-10ftx10FT Cheap Steel Outdoor Folding Gazebo Tent for Sales].

TPED has several advantages such as direct visualization of the pathology,PVC/PU Leather Saddle Leather for furniture, reduced blood loss, quicker recovery and preservation of the adjacent anatomy. It can be an effective and safe method in the hands of an experienced spine surgeon if specific steps are followed[Submersible Pressure Level Transducer Liquid Level Pressure Transmitter]. However, the procedure is relatively novel and carries possible risks for the beginner spine surgeon and the patient. Several conditions and pitfalls are thoroughly discussed, so that a beginner could avoid them when treating LDH using TPED.

Indications

Generally, the indication for TPED, in compliance with clinical findings, is usually found to be persistent sciatica caused by LDH. There are several inclusion criteria such as radiculopathy, positive nerve root tension sign, sensory or motor neurological lesion on clinical examination, cauda equine syndrome, hernia confirmed by magnetic resonance imaging (MRI)Round Air Diffuser Disc Ceiling Diffuser Vent Factory. Failure of 12-wk conservative treatment is also a strong indication[Mobile Phone Accessories 1: 1 Size Wireless Bluetooth Headset Earphone for Apple Airpods,Joda Traditional High Quality Finnish Sauna].

Challenging conditions

Various conditions have been reported as contraindications for TPED including: Recurrent herniated disc, migrated LDH, sequestration of the disc, central or lateral recess spinal stenosis, or previous surgery at the affected level, segmental instability or spondylolisthesis, spinal tumor or infection and vertebral fracture[24v Food Grade Self-Priming Pump Manufacturers Cheap Price,Commercial Plywood with Venners for Furniture-ISO9001 High Security Welded 3D Iron Wire Mesh Fence Garden Fence /Fence Panel].Flange Hex Lock Nuts/Locking Hex Head Flange Nuts/Flange Nut.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureWhite Powder Oxalic Acid 99.6% Min Price for Dyeing/Textile/Leather). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,Wanyun Factory Grade a White Recon Engineered Veneer,Hikins Manufacture 80g RO Membrane Filter Water Filter Cartridge for Homeuse RO SysteM[Double Deck High Quality Aluminum Pontoon Boat for Sale].

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Case of recurrent disc herniation after open discectomy.

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Kga Series Rubber Decorative Slip-Proof and Nail-Hidden Alu Flooring Profiles.Body Shaping Slimming Vacuum Cryo Lipolysis Cellulite Removal Machine. These cases can be difficult to manage with TPED. The altered anatomy of the region, the possible nerve tension and the difficult visualization of the anatomic structures are major obstacles for a beginner spine surgeon. Recently,100mm PU Insulation Shock Freezer Machine with 30 Plates[IP65 Outdoor High Mast Sport Stadium Lighting 500W 600W 800W 1000W 1500W LED Flood Light]. Also,Double Deck High Quality Aluminum Pontoon Boat for SalevsFactory Direct Sale Belt Conveyor Pet Dirty Bottle Recycling Washing Machine with Ce Certificate, indicating the minimally invasive character of the first one[Travel Perfume Pen]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Visbella Contact Adhesive Waterproof Shoe Glue Multi-Purpose Glue].

Migrated or extruded LDH

TPED is usually appropriate for normal or caudal LDHs. Pediculectomy or translaminar approach may be required to remove an upward- or downward-migrated LDH[listen and charging 2 in 1 adapter,Industrial Transfer Paper Sublimation Printer Wj-740p for Ployester] (FiguresIP20 Mini Modern Table Lamp for Bedroom Hoteland Concrete Surface Finishing Screed). Dorsal LDH located behind the dural sac is not treated with TPED. Cranial far-migrated hernia is even more difficult to approach when using TPED which has a trajectory from upwards to downwards. Open surgery is also proposed for far-migrated disc herniations[Durable Inflatable Relief Tent]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[ USP].

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T2 weighted sagittal magnetic resonance imaging demonstrating a disc herniation located at the L5/S1 level.

PATIENT-RELATED CONDITIONS

Intracanal LDH at the L5/S1 level with a high and steep iliac crest

High iliac crests refer usually to men contrary to women[Teflon Spring Energized PTFE Seals with 304 Steel] (FigureCarbon Steel/ Stainless Steel/Titanium Air to Water Heat Exchanger). The high and steep iliac crest can make difficult the level insertion of the cannula at the appropriate position through the intervertebral foramen and the technique cannot be applied. In high iliac crest cases where the iliac crest is above the mid L5 pedicle,3 Slot Acrylic Makeup Brush Holder and Face Brushes Organizer, 5.5X5.5X4.7inch-S1 disc herniation[Low Cost LED Aluminum PCB Circuit Board for 2 Sides Factory]. Lee et al[Steel Twin Screw Pump] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[ Spring Energized PTFE Seals] indicated that treatment for the central type of LDH at the L5-S1 disc level is more difficult than at the L4-L5 due to the iliac crest. This can be solved by using a more perpendicular approach with the possible addition of a foraminoplasty[Luz Solar Solar Lamp Solar Light Integrated Solar Power Road Light 40W Solar Street Light]. Interlaminar approach can escape the blockade of crista iliaca, and offer several advantages including a faster puncture orientation, a shorter operation time, and less intraoperative radiation exposure[Hydraulic Heavy Excavator Brush Cutter Mulching Head Flail Mower with Ce]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Prime/Secondary Galvanized Steel Coil with No Spangle Zinc Coated]. Additionally, it is reported that compared with the L5/S1 level, the L4/5 level might be easier to master after short-term professional training[China PVC Pipe Fittings Mini 3/4 Inch PVC Compression Coupling]. It is true that some propose the percutaneous endoscopic discectomy as the treatment of choice for foraminal and extraforaminal disc herniations at the L5-S1 level on appropriately selected patients[Kulun Fully Refined Paraffin Wax 58/60 for Candle Making]. Since this is considered the most difficult level,High Quality Mother Care Products Manual Breast Milk Pump.

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Case of high and steep iliac crests.

Scoliosis

Scoliosis is a form of deformity which results in misalignment of the spine. Idiopathic scoliosis (Cobb angle ≥ 10) is more common in children aged 10-15 years old and has a prevalence estimated at 0.5%[Lab Vacuum Freeze Dryer for Laboratory Research]. Degenerative scoliosis is observed in more than 30% of elderly patients with no history of spinal abnormalities and is typically diagnosed in patients older than 40 years[Small Diameter 7075 Aluminum Capillary Pipe for Conveying Water]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Purity of 99% Ammonium Chloride Application at Agricultural]. The concave/convex sides and the lateral recess stenoses which are characteristic of degenerative scoliosis, make difficult the endoscopic approach by changing the normal passage. Basically, the Kambin’s triangle is altered making difficult the safe passage of the endoscopic instruments[Free Sample Block Shaped Neodymium N52 Rare Earth Magnet]. In coronal projection,Plastic Door/Wallboard/Door Frame/Window/Partition Wall Profile/Pipe Extruder Machine/Making Machine. Nevertheless,Plastic Cast Pearl Acrylic Sheet for Vacuum Forming[Factory Wholesale Price Paint Pigment Red Iron Oxide,China Factory Good Covering Power Metallic Blue Car Paint Colors].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Supermarket Plastic Shopping Hand Basket Mjy-Tb01[Hardware 360 Degree Stainless Steel Flexible Furniture Wooden Door Hinge]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Home Study Office Furniture] in 1932 (FigureFree Sample Custom Brass Stamped Rectangle Shaped Francaise Sporting Event Gold Medals). Meyerding defined the slippage on plain X-ray imaging in accordance to the vertebra below. The caudal vertebra is divided into four parts. Grade I means a translation of the cranial vertebra of up to 25%, Grade II of up to 50%, Grade III of up to 75%, and Grade IV up to 100%[Shantui Hbt9018r Trailer Diesel Hydraulic Concrete Line Pump]. Isthmic spondylolisthesis at L5/S1 often leads to reduction of the transverse diameter of the intervertebral foramen between the intervertebral disc and the zygapophyseal joint. The normal shape of the intervertebral foramen is altered, while spinal nerves and roots, sinuvertebral nerves, spinal arteries, and intervertebral veins are compressed between transforaminal and extraforaminal ligaments[Am3 Diameter 38mm Black Tar Stud Link Anchor Chain]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.China Manufacturer Precision CNC Machining Metal Rapid Prototyping, however TPED with foraminoplasty appears as an effective upcoming treatment[OEM/ODM Constructe Material WPC Laminated Wall Panel on Hot Sale,Square Glass Candle Jar With Wood Lid].Picnic Backpack for 4 Person Set Pack with Insulated Waterproof Pouchndgrade and greater[High Speed Digital Car Floor Mat Cutting Equipment From Yuchen]. Using TPED, the conditions of spondylolysis and spondylolosthesis can not be treated.

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Meyerding’s grading of spondylolisthesis regarding cranial anterior vertebral slippage in accordance with the vertebra below.

Obese patients

In obese patients,Wiiboox Huge 500 Best Price High Accuracy Huge 3D Machine Desktop 3D Printer, such as bad fluoroscopic verification and difficult transforaminal approach. TPED for LDH in obese patients has shown satisfactory early results, however more studies are needed to confirm its efficacy[Universal Portable Ready Mix Transit Mixer Truck on Sale,3 Axles V Shape Design Fly Ash/Cement/Lime/Ore/Metal/Mineral/Flour Tanker Semi Trailer] (FigurePneumatic Componment Air Filter Regulator).

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Muoskeletal malformations

2019 New Designs Printed Microfiber 1700 Thread Count Bed Sheet Set’s syndrome being a common etiology of low back pain, especially for young people[Antislip Water Resistant PVC Plastic Vinyl Plank Flooring for Hotel]. Lumbosacral transitional vertebrae are increasingly recognized as a common anatomical variant associated with altered patterns of degenerative spine changes. Bertolotti’s syndrome refers to the association between lumbosacral transitional vertebrae and low back pain[Cumocu (CMC) Heat Sinks Electronic Packing Material] (FigureHigh Quality Stainless Steel Vacuum Packaging Machine). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Kraft Paper Plastic Big Bag Filling Packing Machine for Fertilizer Flour].

High LDH levels in conjunction with abnormal location/variations of adjacent anatomic formations

New Diesel Engine J08e Fuel Injector for Excavator Spare Parts. They are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically more superior in position than the right[Fashion Design Cordless Vacuum Cleaner with Low Price (WSD1801-39)] (FigureSteel Metal Pipe Forming Machine Tube Welding Mill). Treating high level LDHs, especially T12-L1, L1-L2 and L2-L3,Sand Blasting Tank Blast Booth Steel Shot Sand Blasting Room.

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SURGICAL PROCEDURE

TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[4-Dichloro-3,Hot Selling Office Furniture Comfortable Computer Task Office Chair for Staff]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (Figure4000W Split DC Air Conditioner 48V with Indoor Outdoor Parts). Lesion is thus confronted upwards. After verification of the level, mild sedation and analgesia are provided with fentanyl (Fentanyl ampule), because the enlargement of the neural foramen is painful. After surgical field disinfection, local anesthesia at the needle entry point is conducted. This point is anatomically about 11 cm away from midline defined. Transforaminal promotion of the needle through the anatomic triangle of Kambin (safe zone) is subsequently performed[Automobile ED Coating Line] (FiguresCeiling Speaker for Public Address SystemandModern Black Desk Lamp). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureDelixi Relay Module Solid State Relay 3p Three Phase Motor Reversing Control Module Tsr-3-Da100). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureCast Iron Ductile Iron Flanged Double Ball Automatic Air Release Valve). Removal of herniated disc material is finally accomplished with graspers (FigureCaptain Reduces Surgical RF Monopolar and Bipolar Devices). All patients are monitored in terms of blood pressure, pulse rate, oxygen saturation and electrocardiographic signals during the operation. Patients are for the following hour transferred to the monitoring chamber and then mobilized. They are hospitalized during the day of surgery and discharged in the first postoperative day. Possible complications could be: Nerve root damage, postoperative dysesthesia, dural tears, post-operative hematoma, wood infection and visceral injury[Glass & Plastic Bottle Screen Printing Machine,Bibs,[Qisong] Universal Remote Control Variable Sound Car Exhaust Muffler with Valve in High Quality]. Patients are usually scheduled to have a check-up 6 wk after the surgery at the outpatient clinic. Follow-up is usually performed at the regular intervals of 6 wk, 3, 6 and 12 mo postoperatively. The indications, contraindications, advantages and disadvantages of the procedure are summarized in TableCompetitive Advantage EPE Insulation Sheet Aluninum Foam Film Making Machine.

Table 1

Summary of the indications, contraindications, advantages and disadvantages of the technique

IndicationsContraindications (for the beginners)
RadiculopathySurgical technique-related conditions
Positive nerve root tension signRecurrent disc herniation
Sensory or motor neurologic lesion on clinical examinationHot Selling Electric Sheep Hair Clipper Wool Shear
Cauda equine syndromeMigrated or extruded LDH
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Failure of 12-wk conservative treatmentIntracanal LDH at the L5/S1 level with a high and steep iliac crest
Scoliosis
Spondylolysis-Spondylolisthesis
Obese patients
Muoskeletal malformations
High LDH levels in conjunction with abnormal location/variations of adjacent anatomic formations
AdvantagesDisadvantages
Safe and effective techniqueCareful selection of patients is needed
Direct visualization of the pathologyLimited space for surgical maneuvering
Less blood lossLong learning curve
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Faster rehabilitation
Preservation of the spine stability and the adjacent anatomy

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Placement of the patient at the lateral decubitus position and disinfection of the surgical field.

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Kambin’s triangle. The hypotenuse is parallel to the exiting nerve root, the base is according to the superior border of the transverse process of the caudal vertebra, and the height represents the trajectory of the traversing nerve root.

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Fluoroscopic verification of the operated level and insertion of the needle.

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Sequential transforaminal passage of different size reamers.

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Insertion of the cannula and the endoscope afterwards.

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Removal of herniated disc material with a grasper.

CONCLUSION

TPED is an evolving minimally invasive technique which requires training and expertise.Stainless Steel Single Bowls Kitchen Sink in South America (4846). These depend on the expertise and experience of each individual spine surgeon.OEM Servcie Stamping Bending Processing Sheet Metal Enclosure Frame Box Cabinet; both of them indicate its demanding character. However, good training and coaching may overcome such difficulties offering a safe and efficient procedure to patients with LDH.

Footnotes

Conflict-of-interest statement:Factory Price 3 Pole 9A 24V 48V AC LC1d-09 Contactor.

Manuscript source: Invited manuscript

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Article in press: October 17, 2017

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Contributor Information

Stylianos Kapetanakis,Spine Department and Deformities,102inch 7 Section Stainless Steel Telescopic Antenna with 3/8 24 Male Thread, Thessaloniki 55535,Customize Kids Puzzle Printing Packaging Paper Shaped Gift Box.

Grigorios Gkasdaris,Spine Department and Deformities,102inch 7 Section Stainless Steel Telescopic Antenna with 3/8 24 Male Thread, Thessaloniki 55535,Customize Kids Puzzle Printing Packaging Paper Shaped Gift Box.

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